Journal of Head Trauma Rehabilitation最新文献

Objective: This study aimed to assess the prognostic value of various frailty assessment tools in predicting 30-day mortality and Glasgow outcome scale (GOS) at discharge in elderly patients with traumatic brain injury (TBI). Additionally, the study evaluated the role of muscularity as surrogate for frailty in the context of TBI.

Setting: Data were collected from patients treated as inpatients in a single hospital.

Participants: All patients aged 60 years or older who were admitted for TBI between 1/2010 and 12/2020.

Design: A single-center study, with retrospective analysis of clinical notes and computed tomography (CT) imaging at admission.

Mean measures: Assessment of frailty by different frailty grading scales, comorbidities by the Charlson Comorbidity Index (CCI), assessment of muscularity by muscle area measurements and their association with outcome of TBI.

Results: A total of 1104 patients with a median age of 78 years (IQR 72-84) were identified. The overall mortality rate was 12.9% (n = 137). Multivariate regression models identified frailty measured by the Clinical Frailty Scale (CFS) ( P < .0001) as predictive variable for short-term mortality and the CCI as predictive variable for GOS at discharge ( P = .009); muscle area measurements as surrogate markers of sarcopenia were not associated with outcome in our cohort. Implementing frailty as measured by CFS and CCI into prognostic models for short-term mortality increased their predictive power (increase of area under the ROC curve from 0.897 to 0.919).

Conclusions: Geriatric-specific models are necessary for a more accurate prognosis estimation of elderly patients with TBI. Our findings suggest that frailty measured by CFS and assessment of comorbidities by CCI adds prognostic value, while muscularity at various locations (as assessed in CT imaging) had no effect on 30-day mortality after TBI.

Objective: Describe epidemiology of pediatric patients with concussion and relationship of injury characteristics and demographic variables to symptom resolution.

Setting: Outpatient hospital system multidisciplinary concussion clinic.

Participants: N = 1653, 6- to 18-year-old patients with concussion.

Design: Retrospective of patients with concussion seen between 2013 and 2019. Rivermead post-concussion symptom questionnaire was completed at each visit. Demographics and injury characteristics were extracted, and income tertiles were calculated by zip code.

Main measures: Descriptive statistics. Multivariate analysis of variance and Cox regression analysis of demographic variables and injury characteristics with time to symptom resolution.

Results: Patients were 44.5% (n = 735) female, 53.5% (n = 885) male, and 2% (n = 33) other/not available. About 376 (22.7%) patients were 6 to 12 years old, 1277 (77.3%) were 13 to 18 years old. Median family income tertiles were <$63 798 (n = 494 [29.9%]), $63 798 to $82 171 (n = 571 [34.5%]), and >$82 171 (n = 545 [33%]). Time to presentation was longer for female patients ( P < .0005), patients with non-sports-related concussions ( P < .0005), and patients in the lower family income group than the middle- ( P = .02) and high-income groups ( P = .003). Average symptom resolution was 41 days, with higher initial symptom scores (hazard ratio 0.97; 95% confidence interval (CI), 0.97-0.98; P < .0005), female sex (hazard ratio 1.31; 95% CI, 0.1.18-1.47; P < .0005), older age (hazard ratio 1.17; 95% CI, 1.03-1.33; P = .015), and having a psychiatric diagnosis (hazard ratio 1.33; 95% CI, 1.15-1.54; P < .0005) predicting longer recovery time.

Conclusion: Pediatric patients presenting to a specialized multidisciplinary concussion clinic possess several similar predictors of protracted symptom recovery when examined against other cohorts described in the literature, including female sex, longer time to initial presentation and initial concussion symptom burden. In this study, children with non-sports-related concussion have different clinical courses than those with sports-related concussion, and children 6 to 12 years old recover more quickly than adolescents. These findings, in combination with existing literature and future prospective studies, can be used to counsel patients regarding expected resolution of concussion symptoms and help direct resources toward those patients at risk for protracted recovery.

Objective: Utilize path analysis to examine the concurrent associations of traumatic brain injury (TBI) and severe limb injury (SLI) with death by suicide mediated by psychological health (PH) conditions and substance use disorders (SUDs).

Setting: Archival career and medical data were obtained from the Career History Archival Medical and Personnel System, the Expeditionary Medical Encounter Database, and the Defense Suicide Prevention Office Suicide Data Repository.

Participants: Service members of the air force, army, marines corps, and navy who served more than 30 consecutive days between September 11, 2001, and September 30, 2016.

Design: This retrospective cohort study utilized path analysis to examine associations among TBI, SLI, PH conditions, SUD, and death by suicide. Stratification by TBI was tested.

Main measures: Concurrent associations of 2 focal predictors, TBI and SLI, with death by suicide were investigated, mediated by PH conditions (ie, posttraumatic stress disorder, depression, or anxiety disorder), and SUDs (ie, alcohol use disorder or other drug use disorder), adjusting for age, sex, race/ethnicity, service branch, and officer status.

Results: In preliminary analyses, TBI, SLI, PH conditions, and SUD were all independently associated with death by suicide. In the first path model, neither of the direct effect of SLI or TBI on death by suicide were significant. TBI shared a stronger association with PH conditions and SUD than SLI did; the association between SLI and SUD was negative. When stratified by TBI status, the association between SUD and death by suicide was stronger among those without (vs with) TBI.

Conclusions: Findings suggest complex and nuanced associations between TBI, SLI, PH conditions, SUD, and death by suicide, and underscore the importance of integrated and holistic treatment of injured military service members.

Objective: To assess the reliability, construct validity, and screening accuracy of the Patient Health Questionnaire-2 (PHQ-2) and the combined PHQ-2/PHQ-9 to detect major depressive disorder (MDD) in persons with traumatic brain injury (TBI).

Setting: Level 1 trauma center.

Participants: Participants were 135 adults within 1 year of sustaining complicated mild, moderate, or severe TBI, initially recruited for a depression treatment trial.

Design: Screening validity study relative to structured diagnostic assessment.

Interventions: Not applicable.

Main measures: PHQ-2 and PHQ-9 depression scales, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Results: The optimal cutoff for the PHQ-2 alone is a score of 2 or more which results in a sensitivity of .86 and a specificity of .83. When the PHQ-2 and PHQ-9 are combined in a 2-step process, the optimal cutoffs are 1 or more on the PHQ-2 and a total of 5 or more of the 9 PHQ-9 symptoms endorsed at least several days in the past 2 weeks. This resulted in a sensitivity of .93 and a specificity of .89 and only 53.6% of patients needed to be administered the entire PHQ-9.

Conclusion: The 2-step PHQ-2/PHQ-9 screening process described here represents an efficient, reliable, and valid means of detecting MDD in people with TBI. Results suggest that the generic PHQ-2/PHQ-9 depression screening parameters adopted within large U.S. federal entities may disadvantage people with TBI.

Background: Early physical activity (PA) after concussion may aid in symptom recovery, though its impact on other recovery domains, such as cognitive functioning, remains less explored.

Objectives: (1) Examine the association between early PA (within 7 days post-injury) and cognitive inefficiency and impairment 4 weeks after pediatric concussion; (2) investigate the association between early PA and cognitive outcomes (memory and executive functioning, information processing speed, attention, visual-motor processing, and vocabulary) 4-week post-concussion.

Setting: Emergency departments (EDs) of four Canadian pediatric hospitals within the Pediatric Emergency Research Canada (PERC) Network.

Participants: Children aged 8-18 years presenting to the ED within 48 hours of a head injury and diagnosed with a concussion.

Design: Planned secondary analysis of data from a prospective multicenter cohort study.

Main measures: Participants' PA level was assessed at 1-week post-concussion through a self-report questionnaire in which they had to indicate their current level of recovery in terms of return to physical activities and sports. Early PA participation was defined as any level of PA other than "no activity" at the 1-week follow-up. Participants underwent comprehensive neuropsychological testing at 4-week post-concussion. Primary outcome measures included cognitive inefficiency and impairment (≥2 outcomes with z < -1.0 SD or <-1.5 SD below the normative mean, respectively). Secondary and tertiary outcome measures include t-scores and scaled scores from the 10 neuropsychological tasks, transformed to z-scores.

Results: Early PA was not significantly associated with the likelihood of cognitive inefficiency or impairment ( P s ≥ .38). The early PA*sex interaction was related to verbal cognitive flexibility ( P = .02), with females engaging in early PA having better scores. Moreover, the early PA*age interaction was associated with attention ( P = .03), with younger children engaged in early PA performing worse.

Conclusions: Early PA has no overall association with cognitive inefficiency or impairment but may be differentially associated with certain cognitive outcomes by age and sex.

Objectives: To examine the active cervical range of motion (aCROM) in 15- to 30-year-old patients with high levels of persistent post-concussion symptoms (PCS) 2-6 months after a mild traumatic brain injury (mTBI) compared with healthy individuals. Additionally, we examined the association between aCROM, the severity of PCS (measured by the Rivermead Post-Concussion Symptom Questionnaire [RPQ]), and the pericranial tenderness score (pTTS).

Setting: A research outpatient clinic at a rehabilitation hospital in the Central Denmark Region. Patients were recruited by referral from general practitioners or emergency departments.

Participants: Young individuals (aged 15-30 years) with high levels of PCS (n = 108) within 2-6 months after a direct head trauma. Reference data of aCROM was obtained from a published study conducted on healthy individuals (n = 100) (aged 20-29 years).

Design: Cross-sectional study using baseline data from a randomized controlled trial examining the effect of a non-pharmacological intervention for PCS.

Main outcome measures: aCROM measured using a CROM 3 device, pTTS, and RPQ-score.

Results: Patients with PCS had a 5% lower mean total aCROM compared with a published reference mean on healthy individuals (mean group difference [95% confidence interval] = -19°[-31; -7.0], P = .002). The reduction in aCROM was primarily driven by a subset of individuals (n = 12). A significant negative correlation was found between total pTTS and total aCROM ( ρ  = -.43, P < .001). There was no significant correlation between the RPQ score and the total aCROM (r = -0.12, P = .214).

Conclusion: The findings indicate that concomitant cervical impairment may exist in a subset of patients with PCS. A clinical implication could be to include systematic neck examination in patients with mTBI to ensure accurate diagnosis. However, further research is necessary before implementing this information into regular clinical practice.

Objectives: (1) To evaluate the implementation of Australia's first occupational therapy-led concussion clinic model into usual practice by examining acceptability and fidelity among clinicians and service users, and (2) to explore the feasibility of embedding outcome measures into the service to facilitate longer-term clinic evaluation.

Setting and participants: A large tertiary trauma hospital service in Melbourne, Australia. Participants were patients referred to the concussion clinic and occupational therapists working in the service.

Design: Prospective, single-site, mixed methods design.

Main measures: Acceptability outcomes were evaluated using clinician interviews and the Client Satisfaction Questionnaire-8. Clinic fidelity was assessed by service usage data. Long-term patient outcomes assessed concussion (Rivermead Post-Concussive Questionnaire), mood symptoms (Patient Health Questionnaire-9), and participation in activities of daily living (Community Integration Questionnaire-Revised).

Results: Over 18 months, 73% ( n  = 177) of patients were referred to the clinic, and 75% attended. Adherence to protocol was achieved; however, the completion rate of post-treatment measures was low. Almost half of the patients required specialist referrals beyond the clinic model for persistent symptoms. The interviewed occupational therapists ( n  = 6) viewed the clinic as a "safety net for patients," believed they were "learning as we go," recognized that the "clinic had potential to grow," but admitted, "we could be doing more." High attendance rates and patient satisfaction further supported clinic acceptance at an end-user level.

Conclusion: An occupational therapy-led concussion clinic is accepted by patients and clinicians to capture the immediate needs of people with concussions after discharge. However, coordinated pathways to multidisciplinary care are needed to address the long-term needs of people with persistent concussion symptoms and problems returning to daily activities.

Objective: This study aimed to (1) determine whether there was an association between a diagnosis of traumatic encephalopathy syndrome (TES) and changes in three specific serum biomarkers, and (2) determine head impact exposure thresholds among both TES+ and TES- groups.

Setting: Data were collected from Cleveland Clinic's Professional Athletes Brain Health Study (PABHS).

Participants: This study included 192 professional combat athletes, 35 years of age and older. Athletes must be actively fighting or retired with a minimum of 10 professional fights over their careers.

Design/intervention: This was a retrospective observational study of the PABHS longitudinal cohort.

Main measures: The generalized linear model with the generalized estimating equation for repeated measurements was used to compare various biomarkers between both active and retired TES- and TES+ groups.

Results: The odds ratio for TES diagnosis was 5.44 (95% CI = 2.48, 11.94; P < .0001) among active fighters and 10.75 (95% CI = 3.52, 32.85; P < .0001) among retired fighters, indicating the odds for a TES diagnosis were over 5 times greater for active fighters with every fight completed at or beyond 30 professional fights. Retired fighters had 10 times greater odds of TES diagnosis with every fight completed at or beyond 15 professional fights. Likewise, the odds of a TES diagnosis were 2.0% (95% CI = 0.3, 3.1; P = 0.0039) greater with each pg/mL increase of glial fibrillary acidic protein (GFAP). No relationship was observed between a TES diagnosis and neurofilament light chain or P-tau231.

Conclusion: This study provides preliminary evidence that progressively elevated levels of the GFAP blood biomarker increase the odds of a TES diagnosis among retired professional fighters. Further evaluation is required to improve clarity and understanding of the relationship between progressive changes in the GFAP blood biomarker and a TES diagnosis, specifically evaluating the duration of chronicity and exposure thresholds.

Objectives: To determine the relationship between exercise tolerance and post-concussion symptom deficits, cognitive function, and recovery duration; (2) examine the longitudinal effect of exercise tolerance on symptom burden over the clinical timecourse of a child's recovery from concussion; and (3) explicate whether exercise intolerance is a significant determinant of recovery in pediatric concussion.

Setting: Pediatric tertiary referral concussion clinic.

Participants: Children and adolescents (aged 6-18 years) presenting to the concussion clinic between January 2015 and December 2022.

Design: Retrospective longitudinal study.

Main measures: Graded exercise test (GXT) data, derived from a standardized treadmill test (Bruce Protocol), was used to measure exercise tolerance following concussion. Based on initial GXT times, participants were dichotomized into 2 groups: (1) exercise tolerant (GXT time ≥9 minutes), or (2) exercise intolerant (GXT time <9 minutes). Symptom burden, cognitive function, and recovery duration were compared between groups. A subgroup analysis of participants requiring multiple clinic visitations was conducted to explore the longitudinal effect of post-concussion exercise tolerance over time.

Results: Of the 603 children presenting to the concussion clinic, 313 participants (mean age ± SD: 13 ± 2 years, 79% male) were eligible. Exercise-intolerant participants (mean GXT [95% confidence interval, CI], 6.9 [6.5-7.3] minutes) reported 2 times greater initial symptom severity ( P < .001) and performed poorly in visual memory ( P = .002) and reaction time ( P = .02) cognitive domains compared to exercise-tolerant participants (mean GXT [95% CI], 12.3 [12.0-12.5] minutes). Recovery time was longer in exercise-intolerant participants than exercise-tolerant participants (mean recovery time [95% CI], 94 [71-116] vs 69 [57-81] days, P = .002). Participants requiring multiple clinic visitations showed improvements in exercise tolerance and symptom burden over time ( P < .001). Significant predictors of prolonged concussion recovery were delayed presentation time ( P < .001), high initial symptom burden ( P < .001), and exercise intolerance ( P < .001).

Conclusion: GXT is a clinically relevant measure to identify children and adolescents at risk of a prolonged concussion recovery.

Objective: To present a method for examining associations among items and total T-score for the Mayo-Portland Adaptability Inventory (4th edition; MPAI-4) that can assist in rehabilitation planning.

Setting: Advanced postacute brain injury rehabilitation programs.

Method: Description and presentation of a rehabilitation planning guide based on Rasch analysis of the MPAI-4 and application in 2 cases of participants with traumatic brain injury.

Results: Initial individualized rehabilitation treatment recommendations derived from examination of the rehabilitation planning guide for specific participants are described.

Conclusions: Systematic examination of a visual depiction of associations among MPAI-4 items and total T-score identified through Rasch analysis is useful for rehabilitation planning and in communication and education with participants and families.